amexnikki23
Guest
Chief Complaint(s): F/U on med
HPI: Established problem follow-up on Anxiety, 26 year old female presents with c/o ANXIETY F/U worsening. She has h/o anxiety but it is getting worse recently.
Denies : SLEEP DISTURBANCE. ENERGY CHANGE. WEIGHT CHANGE. APPETITE CHANGE. CONCENTRATION. ANHEDONIA. SUICIDAL IDEATIONS. RACING THOUGHTS. HALLUCINATIONS.
STRESSORS worsening, at work. SUPPORTS significant, support from spouse. PANIC ATTACKS more frequent panic attacks, more intense. MOOD irritable, anxious, worried about everything, overwhelmed.
She has been using Clonazepam as needed.
Taking Clonazepam 0.5 mg tablet 1 tab(s) once a day prn, Notes: prn
ROS:
CONSTITUTIONAL
no Unusual weight change. no Fever. no Chills. no Fatigue.
CARDIOVASCULAR
no Chest Pain. no Shortness of Breath. no Palpitations.
GASTROINTESTINAL
no Nausea/Vomiting. no Constipation/Diarrhea. no Abdominal Pain.
NEUROLOGIC
no Headache. no Weakness. no Tingling/Numbness. no Visual Changes.
PSYCHIATRIC
Panic Attacks yes. Mood Swings yes. no Depression. Anxiety yes. Stressors yes. no Suicidal Thoughts. no Paranoia. no Hallucinations.
EXAM:
General Appearance: well developed and well- nourished, hydrated, alert and oriented, NAD.
Skin: normal, no rash or skin lesions on exposed skin, moist, warm.
Heart: Regular rate and rhythm, no murmurs.
Lungs: clear to auscultation bilaterally, no wheezes/rhonchi/rales.
Abdomen: Soft, Non-tender, Non-distended with Normal Bowel Sounds, no masses palpated.
Neurologic Exam: alert and oriented x 3, CN's grossly intact, gait normal.
Psychology
Grooming : adequate.
Eye contact : normal. Mood : anxious. Affect: anxious.
Speech: Normal. Association: Normal. Insight: Good.
Judgement: Fair. Hallucinations: None. Thought Process: appropriate.
Memory: Intact. Abnormal Thoughts Perceptions None.
Assessment:
Assessment:
Generalized anxiety disorder - 300.02 (Primary)
Plan:
Treatment:
Generalized anxiety disorder
Start Escitalopram Oxalate tablet, 10 mg, 1 tab(s), orally, once a day, 30 day(s), 30, Refills 1
Notes: Will start SSRI's. Side affects discussed in detail. Warned about succidal ideation in the first week of start. Will follow up periodically. Pt educated with multium medication printout.
HPI: Established problem follow-up on Anxiety, 26 year old female presents with c/o ANXIETY F/U worsening. She has h/o anxiety but it is getting worse recently.
Denies : SLEEP DISTURBANCE. ENERGY CHANGE. WEIGHT CHANGE. APPETITE CHANGE. CONCENTRATION. ANHEDONIA. SUICIDAL IDEATIONS. RACING THOUGHTS. HALLUCINATIONS.
STRESSORS worsening, at work. SUPPORTS significant, support from spouse. PANIC ATTACKS more frequent panic attacks, more intense. MOOD irritable, anxious, worried about everything, overwhelmed.
She has been using Clonazepam as needed.
Taking Clonazepam 0.5 mg tablet 1 tab(s) once a day prn, Notes: prn
ROS:
CONSTITUTIONAL
no Unusual weight change. no Fever. no Chills. no Fatigue.
CARDIOVASCULAR
no Chest Pain. no Shortness of Breath. no Palpitations.
GASTROINTESTINAL
no Nausea/Vomiting. no Constipation/Diarrhea. no Abdominal Pain.
NEUROLOGIC
no Headache. no Weakness. no Tingling/Numbness. no Visual Changes.
PSYCHIATRIC
Panic Attacks yes. Mood Swings yes. no Depression. Anxiety yes. Stressors yes. no Suicidal Thoughts. no Paranoia. no Hallucinations.
EXAM:
General Appearance: well developed and well- nourished, hydrated, alert and oriented, NAD.
Skin: normal, no rash or skin lesions on exposed skin, moist, warm.
Heart: Regular rate and rhythm, no murmurs.
Lungs: clear to auscultation bilaterally, no wheezes/rhonchi/rales.
Abdomen: Soft, Non-tender, Non-distended with Normal Bowel Sounds, no masses palpated.
Neurologic Exam: alert and oriented x 3, CN's grossly intact, gait normal.
Psychology
Grooming : adequate.
Eye contact : normal. Mood : anxious. Affect: anxious.
Speech: Normal. Association: Normal. Insight: Good.
Judgement: Fair. Hallucinations: None. Thought Process: appropriate.
Memory: Intact. Abnormal Thoughts Perceptions None.
Assessment:
Assessment:
Generalized anxiety disorder - 300.02 (Primary)
Plan:
Treatment:
Generalized anxiety disorder
Start Escitalopram Oxalate tablet, 10 mg, 1 tab(s), orally, once a day, 30 day(s), 30, Refills 1
Notes: Will start SSRI's. Side affects discussed in detail. Warned about succidal ideation in the first week of start. Will follow up periodically. Pt educated with multium medication printout.